This entry tells the extraordinary story of how a small group of trainee clinicians, young leaders and improvement facilitators from within the National Health Service (NHS) of England created a call to leadership action that resulted in 189,000 people taking action to improve the care and experience of the patients we serve.

NHS Change Day 2013 was the biggest day of collective action for improvement in the history of the NHS. It made a profound impact across the whole of England and was a force for good in the lives of tens of thousands of patients.

As one of the leaders who took part in NHS Change Day commented on the MIX website:

Change Day fundamentally changed the way I thought about engagement and connection. It was phenomenal to be a part of it and the power that was created by commitment rather than compliance. The even more inspiring element of this was that it was undertaken in [one of] the most hierarchal organisations in the world. The breaking down of barriers and liberating staff to make a difference was brilliant - and I know it made a difference to people's lives (both staff & patients)

Change Day 2013 was an extraordinary moment in the history of the NHS. It taught us that EVERYONE is a potential leader of change, that large-scale improvement is possible and that the best way to do it is through connectivity, collective commitment, action and by keeping it simple. It was about making big change happen, not just thinking about it, analysing it or suggesting how to do it but just by doing something better together in an act of collective leadership.

The team is now busy planning NHS Change Day 2014, with a goal of 500,000 people pledging and undertaking acts of change that will make a positive and sustainable impact for patients. Discussions are taking place with healthcare activists in 16 other territories across the world who were inspired by NHS Change Day 2013 and want to help to grow Change Day 2014 into a global movement that will impact on the care of many millions of patients.

This story exemplifies three of the big challenges ("moonshots") of MIX:

Redefine the work of leadership: The English National Health Service, as a large and complex system, has traditionally defined its leadership in terms of structures and positional authority. However, the scale of change that the NHS now requires is unlikely to be delivered within that leadership mindset: however hard we try to minimise bureaucracy, the very nature of hierarchies and standard management processes make them risk averse and difficult to change. "Leadership everywhere" in an NHS context is about people at every level of the system, with or without positional authority, wielding positive influence and taking responsibility for change. NHS Change Day is a catalyst for this kind of leadership transformation and creates conditions for service transformation

Expand the scope of employee autonomy: Many front line staff in the NHS felt that they couldn't make even small changes without asking for permission from their line managers. They would not have defined themselves as leaders prior to Change Day. NHS Change Day has been such a positive force in a) showing grass roots teams and individuals that they ARE leaders and they have the power to make positive changes and b) demonstrating to managers just how much creativity, energy and passion for change their teams have, when the context is right. In fact, in itself, NHS Change Day was a powerful symbol of taking action for positive outcomes rather than waiting for permission; Change Day came about through a coalition of internal NHS improvement facilitators (who had enough clout to garner resources and support from the formal system to enable it to happen) and young leaders/trainee clinicians (who had the informal networks and credibility with the front line that enabled it to fly).

Encourage the dissenters: Around 10% of the patients who use NHS services are harmed by the NHS. Healthcare systems around the world that monitor patient harm report similar or higher figures. We want every person who works for and with the NHS to be a dissenter, willing to challenge the status quo: systems, processes and cultures that lead to poor care. This isn't just about speaking up when bad things happen (which is very important) but about taking action in our own spheres of influence to make improvements for patients every day. NHS Change Day has built the foundations for a movement of "dissenters"; those who support the patient-focussed mission of the NHS and who are willing to go the extra mile, individually and collectively, to challenge existing arrangements and help create some "new truths" for the NHS.

Context

The English National Health Service (NHS) is the biggest health system in the world, serving the needs of a population of 54 million people. It’s also the 5th biggest employer in the world with 1.7 million employees - only the US Department of Defense, the Chinese Red Army, McDonald’s and Walmart have more people. Every day, a million patients use the services of the NHS. It’s a massive, complex system, operating at the interface between birth, life and death. Whilst the NHS performs well compared to many other healthcare systems, it sometimes lets people down badly and it’s REALLY hard to change it

The British National Health Service was founded just after the end of World War Two, as a bold move to build social solidarity for health and create a better future for a nation that had suffered such hardship and loss in the preceding years. As a result, for the last 65 years, the NHS has provided free healthcare to the people of Britain, regardless of ability to pay, funded by direct tax. We, the British people, have a special relationship with our NHS. In a recent national survey, people said they cherish the NHS more than the Royal Family or the armed forces. The politician Nigel Lawson famously described the NHS as "the closest thing the English have to a national religion".

However, like many healthcare systems across the world, the NHS faces unprecedented challenges; pressures of economic constraint, demographic change and rising patient and public expectations. Basically, expenditure is rising at a rate that is higher than the economy can provide and this financial trajectory makes the current NHS system unsustainable. Unless the system of delivery is transformed, there is a real threat to the timeless and passionately-held principles of free healthcare upon with our NHS was founded and which remain at its heart to this day.

To meet this challenge, we have to change our mindset about two key issues:

1. Leadership for change As the leadership task of healthcare becomes increasingly complex and grows in scale, we need many more leaders than ever before. The pool of leadership talent that we need to create the future won’t just include the “usual suspects” with formal roles within the NHS hierarchy. We have to move beyond positional authority and create leaders everywhere. This means we must think widely and diversely about who our leaders are; they include front line staff, clinicians in primary care, community leaders, people who use services who want to help shape the future and our partners in local government. We have to redefine what being a leader actually means; Daniel Pink describes leadership as being about autonomy, mastery and purpose. We have to create ways for each of our "leaders everywhere" to feel confident to take initiative and responsibility, to continously improve themselves and the services they deliver and to feel like they are a key and valued player in our higher purpose of outstanding care for everyone, at the point that they need it, regardless of ability to pay.

2. Resources for change. Usually when we think about resources for change we think about economic resources (budgets, technology, project managers etc). These resources are limited and finite; when we have used them up there are no more. However, we needed to consider the “natural” resources that exist: the sense of shared purpose around the NHS and the values and principles of common good that it stands for which energise the goodwill and commitment of NHS staff, patients and citizens. The great thing about these resources is that the more we use them, the more they grow.

NHS Change Day 2013 is an exemplar case study of how to liberate “leaders everywhere”. The story begins in mid 2012 when a group of trainee doctors and healthcare improvement leaders stepped up to unleash these resources and be at the forefront of change by launching the very first “NHS Change Day”, to take place on 13th March 2013. We were seeking to harness the creativity, innovation and energy of people who work for and with the NHS in a single day of collective action. The shared purpose of Change Day was to organise a grass roots movement of people to pledge to take a specific action to improve the outcomes and experience of care for patients on a sustainable basis. The initial goal was to mobilise 65,000 people - 1,000 for each year since the NHS was established. This would make it the single largest simultaneous improvement event in the history of the NHS and, therefore, one of the largest of any organisation in the world.

This story describes the journey taken by this leadership team and shares some examples of the difference made through the first NHS Change Day. We not only reached our 65,000 aim, but smashed it, receiving a staggering 189,000 online pledges of action and subsequent actions for change. Our analysis post NHS Change Day suggests that as many people again took action but didn’t register their pledges on the online pledge wall. The true total is probably nearer a third of a million people.

Today, we believe that we are at a point in NHS history when there is a greater need than ever for those who value the NHS to contribute to making it fit for the future. NHS Change Day and the movement of change leaders it has sparked shows we can rise to that challenge.

Right from the moment we started talking about NHS Change Day, the most common piece of feedback we got was “why hasn’t anyone thought of doing this before?” It was people taking action on a collective basis that led to the creation of the NHS 65 years ago. Since that time, people who have cared passionately for the ideals of the NHS have played their part in changes to take the service and its values forward.

President John F Kennedy once quipped that “victory has 100 fathers and defeat is an orphan”. In the case of NHS Change Day, it is a victory for a burgeoning social movement for change owned not by hundreds but by tens of thousands of leaders across the NHS and beyond.We cannot name all of them individually here, but each and every one of them can be found on our Pledge Wall. This story is submitted with our heartfelt appreciation to all of them for taking part. Anyone can join them by getting in touch with us and joining our change movement via our social media channels.

Triggers

NHS Change Day should be seen in the context of a decade long strategy within the NHS, led by Helen Bevan, to apply social movement principles to improving healthcare. An initial publication, "Towards a Million Change Agents" written by Paul Bate, Helen Bevan and Glenn Robert in 2004 has had more than 3 million downloads and influened a generation of leaders of healthcare improvement. This approach was a response to some of the existing change initiatives in the NHS at the time, typically using Lean, Six Sigma and other industrial approaches to process change.Many of these projects were delivering promising results but mostly on a small scale.

We needed additional thinking about how to call people to action for change across a whole system. What could we learn from the leaders of the great social movements, people who typically had few resources for change (in an economic sense) and no hierarchical or positional power, yet were able to deliver change on a massive scale? We continued to test and build these approaches over a period of time.

In 2009, inspired by the use of community organising principles in the Obama for America election campaign, we wrote to Marshall Ganz at the Kennedy School of Government who was the intellectual architect of the grassroots approach that the Obama campaign adopted, asking him to help us to transform the NHS. As a result, a number of NHS improvement leaders were trained in the skills of community organising and Public Narrative which were then cascaded to “healthcare radicals” throughout the NHS system. One of the outcomes of this work was a nationwide “call to action” to reduce the unwarranted prescribing of antipsychotic drugs to people with dementia (basically more than 100,000 vulnerable, mostly elderly, people in England were being given powerful brain-changing drugs inappropriately. These drugs should only have been given to people with schizophrenia and psychosis). We were able to mobilise a huge community of leaders to help put right an intolerable situation; this included doctors and nurses, advocacy groups, families and “dementia-friendly” communities, senior leaders of major drug store chains and owners of private care homes. This call to action contributed to a 51% reduction in the prescription of antipsychotic drugs to people with dementia across England. You can read about it in this learning evaluation by a team from the University of Manchester.

By 2012, we started to notice how many young leaders and trainee clinicians were getting involved in social movement/community organising activities for healthcare improvement. Generation Y was coming of age in healthcare! Five years earlier, it had often felt impossible to engage young NHS leaders in improvement activities as they were so focused on completing their training and/or kickstarting their careers. Now a growing cadre of young leaders was active on social media, stepping up to engage in change and were passionate about making a difference for patients. There was a growing sense amongst more mature (established) members of the NHS improvement community that these young leaders were the key to transformational change. When we look at the history of revolution and radical change, there are typically young leaders at the vanguard. In 1948, it was a new young generation of doctors who had come through the war that were instrumental in overthrowing the established order and securing the set-up of the NHS.

So NHS Change Day started with a conversation on Twitter between some trainee doctors (usually perceived as powerless and at the bottom of the NHS hierarchy) and some NHS improvement leaders in the summer of 2012. By “improvement leaders” we mean people who have a full time job in the NHS supporting and facilitating change. We began exchanging ideas and a vision about how we could bring together staff across the NHS and its supporters to produce positive change and improvement.

We took our initial inspiration from Earth Hour, a worldwide event organised by the World Wide Fund for Nature (WWF), held at the end of March annually, which encourages households and businesses to turn off their non-essential lights for one hour to raise awareness about the need for action on climate change. The event first took place in 2007, when 2.2 million residents of Sydney participated by turning off all non-essential lights. Following Sydney's lead, many other cities around the world adopted the event in 2008. By 2012, it was taking place in more than 7000 cities and towns across 152 countries and territories.

Our initial questions were about what we could do in the NHS that might be our equivalent of turning the lights off. Some of the fundamental questions we considered were:

· What is our objective?

· What shall we use as our goal?

· Should we identify a specific action that we want everyone to take (as in Earth Hour) or should we leave it to people to take an action that is meaningful to them?

· Should we give people themes to pledge about?

· How will we measure the outcomes and impact?

· Who owns Change Day - how do we keep it grassroots?

· How will the change be sustained beyond a single day?

A major difference between Earth Hour and NHS Change Day is that Earth Hour is an umbrella movement that brings many organisations and activists together in a common cause. NHS Change Day was going to be a movement largely INSIDE a hierarchical system. We needed to get the balance right between igniting frontline action AND using the leverage of the hierarchy to make positive change happen without destroying the grassroots power of Change Day.

It was very important that we framed the call to action and its underpinning narrative as about commitment, not compliance. The workforce of the NHS had been used to a decade of top down, performance driven goals, set by national government, based on minimum standards with targets such as maximum waiting times for patients and compliance with treatment pathways. There were heavy penalties for NHS organisations if government targets were not achieved. Even though there was a good intention to the targets regime, it became “have to do” not “want to do” and the strategy created a lot of resentment, particularly amongst the clinical leadership community, many of whom felt that priorities got skewed. Hitting a target treatment time was sometimes inappropriately viewed as more important than giving priority to the most seriously ill person. As soon as a numerical goal got mentioned or an action was specified, people in the NHS assumed it was a compliance target has that was what they expected and were used to.

For NHS Change Day, we wouldn’t be able to build “leaders everywhere” through compliance; NHS Change day had to be underpinned by a massive commitment-driven approach, based on shared purpose. Initially we thought of asking everyone taking part to develop an improvement project inspired by some of the best practice approaches to change that already existed. Some of us thought a target of 500 projects might be reasonable. Others thought we could be more ambitious. At a strategy meeting, the goal of achieving 65,000 online pledges was agreed – 1,000 for every year of the NHS. After brainstorming various ways in which this social movement could be brought about, we developed the concept of a single day of action.

A core leadership team was established for NHS Change Day. It was self-selected, made up of the people who were most active plus some people with critical technical and organisational expertise who were recruited to help. The role of the core leadership team was to organise and mobilise people and to put in place a range of channels, activities and platforms – particularly harnessing social media – to enable existing communities of like-minded individuals amongst the NHS and its supporters to come together for common purpose. The central mechanism to allow them to do so was a web solution allowing people to create a pledge, join existing pledges, comment on any pledges and include the number of people pledging with them.

The improvement leaders on the team were people who were trained in community organising methods and already had experience in leading calls to action. Only two people worked on Change Day full time and then only for three months. Most people on the core team were volunteers and did other jobs as well

Even thought we had bold ambitions for the whole NHS system, we didn’t seek permission from the senior leadership of the NHS to run Change Day. Rather, the core team got organised and just decided collectively to do it. We then worked out how we were going to make it happen. As Marshall Ganz would say, we were “strategically resourceful” We used what resources we could find and work with. For instance, we needed a web platform to host our online “Pledge Wall” for people to post their pledges for action. We identified an existing website that we could adapt. It wasn’t ideal because there was a complex registration system for pledgers to be able to get on the system. It meant that people often had to be very determined if they wanted to pledge and that a large number of pledges weren’t posted. However, it worked well enough and we have learnt a great deal about how we need to do things differently for Change Day 2014. We were also able to frame NHS Change Day as a helpful way of delivering existing improvement priorities and attracted some more resources that way. Overall, it was much more important to build the spirit of volunteerism than to seek a lot of formal resources for the initiative. As Gary Hamel puts it, in the new world, “resources get attracted, not allocated”.

The whole ethos of NHS Change Day was no one needs to ask permission to make positive changes for patients. We didn’t anticipate it in advance but “not asking permission” became a really big theme as a lot of frontline colleagues were at first reticent to take the initiative in their pledges without getting the consent of their line managers. This is a cartoon we produced:

As a core team we used our existing relationships and influences to win people to our cause. Once Change Day started to take off, we got fantastic, active support from system leaders. NHS Change Day was endorsed by, amongst others the Chief Executive of the NHS, David Nicholson, the Secretary of State for Health, Jeremy Hunt and the Mayor of London, Boris Johnson. Once senior leaders started acting as signal generators to the NHS leadership community, many others started to pledge personally and to encourage their workforce to pledge

The foundations of Change Day were built around a grassroots shared purpose - creating a mass movement of “leaders everywhere” working in and with the NHS and demonstrating the difference they could make by one simple act each for sustainable improvement. The only condition for participation was a willingness to publicly make a pledge and to register on the site before doing so.

Key Innovations & Timeline

This is the campaign chart that sets out the key timelines for NHS Change Day and our initial "mountain top goal" of 65,000 pledges

After the launch of NHS Change Day in January 2013, the numbers of pledges started slowly rising. With five weeks to go, the overall online pledge total stood at 5,000. Although the core team knew that a host of organisations and individuals were standing ready to make pledges before or on the day itself, and therefore the 65,000 target was probably achievable, nothing could have prepared us for what subsequently happened.

In the final month before 13th March, NHS Change Day - and the social movement we sought to build and inspire – just ignited.

Feedback and requests for support began to pour in from organisations and individuals, wanting to make their own pledge or support others to do so. Social media channels began to build significant traction and traffic. The online pledge total began to build spectacularly. On 14th February, the total was at 5,000. By 21st February it had grown to 43,000 and by 1st March it stood at 80,169 – breaking through the 65,000 target with two weeks still to go to the event.

The 100,000 pledge mark was broken at lunchtime on Monday 11th March. By the morning of Change Day itself, there were 130,000 pledges registered on the website– double the target.

Liz Saunders from the influential healthcare policy think tank, the Kings Fund blogged and tweeted on the evening before NHS Change Day:

“If ever you're losing faith that there is the energy to make a difference in the NHS…there are more than 130,000 pledges on there, people actively choosing to make a difference to the services they provide and to patient care. It's uplifting.”

Change Day pledges poured into the online site throughout the day, from across the country. The focus of NHS Change Day was England, but people also caught the spirit of Change Day in Ireland and we received 13,000 pledges from there. By the end of Change Day itself, a staggering 182,000 pledges had been received. Over 50,000 had come in on the day. A further 1,000 were added the day afterwards and a further 7,000 before the end of March 2013 – hitting a final total of 189,000 pledges.

The success of Change Day led well-known NHS commentator (and change sceptic), Roy Lilley, to declare

“Sometimes an event comes along that simply and fundamentally changes things. They call it a "gamechanger". The dictionary definition is "a newly introduced element or factor that changes an existing situation or activity in a significant way". Well, I think we have a new Gamechanger. It's called NHS Change Day - it happened this week and it came from the NHS grassroots.”

Originally, NHS Change Day was aimed at “people who work for and with the NHS” and the core team was made up of people who work in the NHS. However, the networks of people who engaged in Change Day went far beyond the boundaries of the NHS.

Innovations

The specific innovations that built our successful movement of “leaders everywhere” were:

· Having an initiative run by young leaders and clinical trainees who view the world in a different way to the established paradigm of change management and (for the more mature members of the core team) having the courage and humility to appreciate that their new approaches might be better

· Viewing the entire workforce of 1.7 million people as potential leaders of change, rather than just those with positional power

· Adapting principles from social movement leaders and community organisers and applying them in an organisational setting

· Making the best of both networks and hierarchies, working through informal networks and communities of interest and creating a genuine grassroots movement at the same time as enabling leaders with positional authority to role model “change leadership” in a new way

· Building the skills and confidence of thousands of thousands of front line staff to lead change without authority and permission

Challenges & Solutions

These were major challenges/risks that the core team identified and the solutions/mitigating actions we put in place:

Challenge

Solution(s)

There had never been a grassroots improvement movement inside the NHS before. The NHS is a system where most of the changes come from policy changes by government, top down restructuring, compliance with assurance regimes and financial incentive systems. Many people did not believe it was possible to build a movement inside a hierarchy

· Work with the hierarchy AND build informal networks for change; understand and respect the power of the hierarchy to both be a powerful lever for change and a barrier of change but don’t let it dictate what happens

· Encourage leaders with positional authority to make pledges for NHS Change Day that role model shared purpose and distributed leadership; show that there are other ways to lead change

· Demonstrate how pledges that are commitment based are just as effective at enabling change and achieving organisational goals as the established levers for change

Many frontline NHS staff don’t see how they can lead change without getting permission/being told what to do by those above them in the hierarchy

· Build “strong tie” support networks so that people in similar roles making similar pledges for change can build alliances and support each other

· Promote the actions of “role model” line managers who create distributed leadership

· Build the movement of confident, capable, frontline leaders who have the skills and courage to lead change

· Let the emerging generation of young leaders show a different way

If the grassroots workforce are going to be “leaders everywhere”, their leaders and managers have to change their leadership mindsets and actions as well

· Help line managers understand the difference between a “good rebel” and a “troublemaker”

· Encourage and support positional leaders to pledge actions that will build the environment for “leaders everywhere”

· Build a narrative for change that promotes new ways of thinking about and leading change

NHS Change Day was a specific day of action. We didn’t want it to be a one off day but a catalyst to enable our “leaders everywhere” to lead change all year round

· Promote pledges that are not just actions on one day but are about on-going change

· Build momentum, energy and outcome measures for Change Day that are not just about pledging on the day but the actions and consequences afterwards

· Make Change Day communication a year round process

How do we ignite the fire of NHS Change Day at scale and enable it to go viral?

· See section on social media strategy below

The role of social media

Social media played a crucial role in the success of NHS Change Day. It was a core part of our strategy of running our change intiative from the viewpoint of young leaders and traineee clinicians. Survey research carried out since suggests that one in three Change Day participants first heard about NHS Change Day through social media (primarily Twitter) closely followed by the personal contacts of the core team itself . Combined, these two channels were responsible for almost two thirds of people (59%) first finding out about Change Day.

Social media was one of the few areas where we commissioned expert external help, rather than relied on volunteers. Joe McCrea, our social media lead designed and led our social media strategy which enabled NHS Change Day to go viral at minimal cost:

· We very quickly established a full suite of social media channels, capable of broadcasting and capturing video, audio and written materials;

· We ensure that all our outputs very quickly and explicitly encouraged participants to fulfill the core function of Change Day – i.e. visit our and make a pledge;

· Initially, we used our existing material captured through traditional means but then added further high-end material at little additional cost by assuming an unofficial role as a central broadcast channel for equally well produced material from the front-line (e.g. a promotional video for Change Day by Leicester University Hospitals);

· We contacted communications and digital teams in other organisations whom we knew would be supporting Change Day, asking them to let us have their own material as it became available – so our own channels could be constantly growing and changing;

· The word began to spread amongst local NHS organisations and pledgees that their own produced material was available on the national site, and our social media communities began to grow as parents and colleagues began to come to our channels and comment on or ‘like’ specific items;

· We relentlessly and instantly cross-fertilised the full suite of our social media channels as new material appeared on one or the other (e.g. tweeting, Facebooking and podcasting audio and video material as it went onto YouTube);

· We spread confidence and a sense of momentum across the NHS by using our Twitter channel as a ‘breaking news’ service – with updates on the growing number of pledges and latest examples of pledges from the frontline;

· We took part in Tweetchats led by established publications in the healthcare world– as well as webinars hosted by ourselves – in the final week before the event itself.

In everything we did, we balanced anarchic and humorous examples of grassroots ideas and pledges from staff throughout the NHS – for example, a 90-second ‘Change Day’ jingle written and performed by staff from Harrogate Hospital, which has become by far the most popular item on our YouTube channel, with over 1,200 views – with a serious message around leadership and change from senior leaders and decision-makers.

Moving forward into 2014, NHS Change Day’s use of social media is being strengthened and deepened through a ‘mobile first’ approach, underpinned by social media and industrial-strength infrastructure:

· to support leaders everywhere in the healthcare system by using social movement thinking in the NHS as an approach of delivering large scale change;

· to measure the social value of NHS Change Day as a bottom up approach for engaging grassroots leaders for levering change at the frontline;

· to inspire leaders everywhere and make it easier for them to participate in NHS Change Day and its associated social movement, make a difference and deliver value;

Sometimes the most profound benefit is the most glaringly obvious. In the case of NHS Change Day, the most profound benefit we demonstrated was that "it can be done". As one of our pledgers - a student nurse - put it when asked what her advice would be to others looking to make improvements to patient care and promote change...."just do it".

Some might have thought - indeed some did think - it a crazy idea to try to get thousands upon thousands of frontline staff across the NHS to commit simultaneously and publicly to change and improvement for no reward other than recognition and support.

But, as one famous agent for change once observed “Here's to the crazy ones…because they change things. They invent. They imagine. They heal. They explore. They create. They inspire. They push the human race forward. And while some may see them as the crazy ones, we see genius. Because the ones who are crazy enough to think that they can change the world, are the ones who do."

Our most important metric - therefore - is the 189,000 pledges that were submitted onto our website for a single day of action - 13th March 2013. And subsequently, the discovery we have made that even this total was a fraction of the pledges actually made and carried out on that day. This made NHS Change Day inarguably the biggest single improvement event in the history of the NHS, and therefore of any healthcare organisation in the world.

As the dust has settled and we have had time to analyse the pledges,learn lessons and hear from the frontline, some other important and striking metrics and benefits have become apparent.

We have proved conclusively that there is a desire and hunger for change and improvement amongst the frontline; receptionists, nurses, doctors, porters, cooks, therapists and so on. And we have shown that our staff don't need to be given direction to initiate or publicly suggest change. Given the opportunity and freedom they will actively and enthusiastically choose to do so.

Survey research we have carried out recently shows that the primary motivation for people to get involved in Change Day was to improve patient care.

Improving patient care was overall the main motivating factor in getting involved, closely followed by "I wanted to make a difference" and "I wanted to learn from others". 80% of respondents who said that "improving patient care" was their motivation, said that it was "very important" in motivating them to get involved in Change Day.

In contrast, the two least motivating factors to get involved in Change Day were "Because I was told to" and "Because I was asked to". This is hugely important in demonstrating our core argument that "inspiration beats compulsion or even exhortation".

There is no doubt that NHS Change Day was a genuine mass movement for change involving thousands of people.

54% of pledges logged on our site involved action taken by a single individual. 71% of pledges involved less than nine people. 94% of pledges involved less than 50 people

The biggest personal impact for participants of involvement in NHS Change Day was involvement and

feeling of making a difference.

This was closely followed by "the NHS benefitted" and "my organisation benefitted". There is clearly a large well of goodwill towards the NHS amongst its frontline staff that we were able to tap into.

We have also demonstrated that there is an enthusiasm for sharing ideas across organisations and learning from others. Six out of ten respondents shared the idea of their pledge with others. This shows that the "inspire and share" emphasis we are planning to develop for Change Day 2014 is going with the grain.

One of the favourite things we can show from NHS Change Day is the power of simple things, particularly when it comes to delivering compassionate patient care. For example, we hold dear the "power of a smile". Pledges encompassing almost 3,500 people involved simply “smiling” with fellow staff or patients, including at including at: Newcastle Upon Tyne NHS Trust; Birmingham Children’s Hospital; Oxford Health NHS Trust; The Christie Hospital; Basildon and Thurrock NHS Trust; Northampton General NHS Trust; Worcestershire Hospital NHS Trust; Shropshire Community NHS Trust; and Chesterfield Royal Hospital.

We have produced a short film we call "The Power of a Smile" - which always provokes nods of agreement whenever we show it at NHS staff and leadership events.

Obviously it would be impossible to list all the benefits and examples of change and improvement across the NHS that were brought about through NHS Change Day. But here is just a sample of them to give a flavour of our collective achivement.

A group of second year student nurses at the University of York pledged to create a mock-ward, with students playing the role of patients. Viewing the ward through a patient’s eyes, the students quickly realised how disorientating and frightening a ward can become for patients when they don’t understand what is happening around them. For nurses used to the jargon and processes of a hospital setting, such lessons are easy to forget. The lessons they learned made such an impact on the University that the curricculum has been changed to include them.

Tollgate Medical Centre, Beckton pledged to switch off the electronic notice board: all clinicians would personally welcome and ‘meet & greet’ patients from the waiting room on NHS Change Day. An unexpected positive for the staff was seeing the rest of the team during surgery meeting and collecting their patients where they would normally be sitting in their rooms alone. Apart from this minor challenge, the staff found it was easy to get everyone engaged with Change Day. The idea of making small changes to improve the NHS was so compelling.

Derbyshire Community Health Services NHS Trust organised over 130 pledges involving over 400 staff. One of the biggest was the mobilisation of over 220 local 'Innovation Scouts'. They also included plans to undertake a 'mystery shopper' approach in service areas and make suggestions on how to improve the patient experience; to obtain patient questions via video and play them back at team meetings to discuss feedback and communication with patients and service users; spending more time each week talking to patients, service users and front line colleagues to understand their experiences and concerns and ‘keeping people motivated during these times of change’. All pledges have been logged locally by the Innovation Hub who will follow up on all pledges within 3 months. The Chief Executive has pledged to report back to the whole organisation on the progress and sustainability of her pledges, leading by example.

In University Hospitals of Leicester Trust, the Procurement & Supplies team pledged to clear out redundant and out of date paper documents in their offices from previous managers and procurement archive area to clear space for operational work. This made a huge difference in the receipts and distribution area within the Trust. 200 archive boxes were taken away and confidentially destroyed.

NHS Arden Commissioning Support, working with their three local Clinical Commissioning Groups, NHS Coventry and Rugby CCG, NHS South Warwickshire CCG and NHS Warwickshire North CCG, helped a fifty-strong NHS Change Day team of staff, lay members and patients to take the message out to communities and subsequently reached thousands of people. They combined this with local press and social media. Around 450 people also completed detailed surveys about local health services in their local area. Over a hundred have agreed to engage with them on a regular basis and have signed up as local Health Champions. The public valued having an opportunity to share their views, knowing what they said on the day will genuinely help to make a change for the better. In addition, more than a hundred patients will be sharing their views with the Commissioning Group on a regular basis from now on in their role as health champions. Analysis from feedback on the day will help inform the Clinical Commissioning Group as they plan local health services in the future. The staff feedback was extremely positive and the event was really valued by those who might not usually be in a public-facing role.

Eastern Cheshire Commissioning Consortium pledged to create a weekly opportunity for all staff to ask the question “what have I done to help a patient this week?” Simple things often work the best and therefore the Consortium placed a large sheet of A4 paper headed “what have you done to help a patient this week?” above the tea and coffee which is the area which gets the most footfall from its teams. What is happening now is that each week on a Friday the team writes down what it is they have done. Examples do not just include what they have done directly as a result of the work that they are ‘employed’ to do but also recognise what they do when they do come into contact with a patient – and that can be a family or friend – be it in the car park, supermarket or on the street.

In Wolverhampton a member of the public, Jeharna South, pledged to go to the children's ward in her local hospital and sing for the children there. In September of 2012 her little brother was knocked over by a car. The way he was looked after by the NHS staff was just brilliant and Jeharna wanted to say thank you.

The same family friend that had first told Jeharna about Change Day also suggested the idea for her to sing as part of her pledge. She says she felt moved by the event, especially when she saw the children she was singing to. They were in a similar position as her brother last year and she knew it is not easy on the families or the children alike.

Other examples of pledges involving personal impact include:

I pledge to make my work colleagues feel supported and valued. To remind them of the great jobs they are doing everyday

I pledge to take part in Tea 4 two - sitting with a patient on a regular basis who doesn’t have visitors and enjoy a cup of tea and a chat,or

As a nurse I pledge to say thank you to the healthcare assistant I work with; asking her what more I can do to support her in her work .

Other pledges involving large numbers of participants included:

I will 're-humanise' my practice of medicine by always using patients' names when talking about them as a constant reminder of individuality ; and

I pledge to taste a variety of paediatric medications I prescribe to my patients .

Other pledges involved more substantial action. For example:A pledge by staff at Queen’s Hospital, Romford, to create a Wellbeing Centre ; or

University Hospitals, Leicester pledging to introduce a more accountable electronic record-keeping system in their dermatology department .

Some pledges involved non-NHS staff doing something that would benefit health outcomes and the NHS from outside, for example a pledge by staff at market research agency MRUK to set up a computer for the day where staff could sign up to become blood, marrow and platelet donors, and place themselves on the organ donation register .

The ThankU4 grass roots campaign pledged on Change Day to seek to boost the morale of healthcare staff by encouraging people to thank each other , saying: “We are a group of doctors/health professionals who believe passionately in the values of the NHS. We feel that everyone working in the NHS deserves to feel appreciated for the work that they do. It doesn’t take much to do this, just a simple “thank you”!”

A group of staff at St Oswald’s Hospital in Ashbourne pledged to get more active in the workplace, as part of their health and wellbeing, and kicked off their efforts by staying late to do a Harlem Shake .

Many had their own Pledge Walls (for example East of England Training Board and Ipswich Hospitals). Sheffield Teaching Hospitals went one better and had its own Pledge Tree.

Delegates from the Department of Health, NHS and the voluntary sector explained why Equality and Diversity must be at the core of Change Day, directly involved with communities and patients at the local level. One member went onto the street around the Department’s headquarters in Londonl, handing out 65 copies of the NHS Constitution whilst engaging with members of the public about how we can improve the NHS.

Lessons

The nine BIG leadership lessons for “leaders everywhere” from NHS Change Day 2013:

1.“Leadership everywhere” happens one person at a time but if we can create common purpose, we can quickly build a movement

2.Being a leader is about choosing to be a leader and running with this (regardless of where you are in the hierarchy) and not waiting for those with positional power to tell you what to do (you might have a long wait and patients might be harmed in the meantime)

3.Consequently, being a “leader everywhere” in the NHS isn’t related to hierarchy or position; and you don’t even have to work in the NHS to qualify as a healthcare leader

4.When front line staff stepped up to the leadership opportunity offered by NHS Change Day, we found that most healthcare organisations actually valued these behaviours, rather than resisted them

5.There were some outstanding senior leader role models from NHS Change Day who inspired us through their pledges and the actions they subsequently took; they showed us that leaders are at their most powerful as role models when they learn, rather than when they teach or tell.

6.Resources for change are abundant but they need to be activated, through shared purpose and relationships

7.Young leaders really do have a lot of the answers to the "leaders everywhere" challenge. Positional leaders need to create the conditions to support them and let them get on with it

8.Individually and collectively, the English National Health Service has an outstanding (often latent) force of leaders everywhere in its ranks. The potential is there to liberate that army of leaders, to deliver the outcomes and experiences that our patients deserve and to build the continuous learning and improvement system that will make the English NHS the safest and best healthcare system in the world.

9.Through our “leaders everywhere”, we can protect and preserve the basic principles of our NHS for future generations

NHS Change Day 2013: the postscript

Since 13th March 2013, many organisations within the NHS have continued to use the principles behind Change Day; the idea of ‘doing something better together’ and the power of giving permission to develop your own change leadership programmes and strategies. Led from the grassroots, this means that sustainable changes are happening on a more frequent basis. For example, Leeds Community Healthcare launched an innovation e-forum on NHS Change Day which has become a platform to allow grassroots members of staff to suggest innovations which they will then be empowered to act upon.

NHS Change Day has allowed the development of self-organising groups where natural leaders are being given the chance to emerge and shine. In the "benefits and metrics" section of this entry, we told how Louise Towse and fellow students at York University used Change Day to run a “virtual ward” and experience the NHS from the patient’s point of view. Beyond the impact this had for the way they will care for patients in the future, this allowed a cadre of future leaders, beyond hierarchy, to grow within the healthcare system. Realising the power they could have when they worked together, the students are now running their own campaign; ‘Every Nurse Matters’ works to promote the positive impact nurses can have and like Change Day, to redistribute the power of nurses to enable them to make long term impacts in the healthcare system, right from the start of their nursing carers.

Moving on to 2014, the Change Day movement will continue. We are aiming for 500,000 people to stand together and deliver quality improvements for Change Day 2014. This is being led not only by the founders of Change Day 2013, but by individuals inspired by Change Day wanting to step up to an NHS-wide leadership role. The core team has not developed a formal hierarchy, allowing anyone who wants to join in its development to be part of the leadership. This is backed up by a “train the trainer” approach, empowering a further generation of aspiring leaders to work together to deliver system-wide change. It is another example of how NHS Change Day is continuing to fundamentally redistribute power beyond the collective action of one day.

For Change Day 2014, there will be further development of simple web based tools, to allow people to join up their pledges and learn and collaborate more effectively. We are in discussion with healthcare activists from 16 other territories across the globe about the potential for Change Day to go global from 2014. We have also been receiving coaching advice from the very generous and collaborative leaders of Earth Hour, now in its eight year as a global force for change. It’s clear that we need to build a ten year strategy for Change Day

Going forward, we hope that the basic tools of Change Day (freedom to act without permission, building solidarity for change, collective knowledge) will motivate and inspire hundreds of thousands “leaders everywhere” to take small steps that together can ensure that our health services can continue to improve patient care on a very big scale.

Credits

Special thanks to:

NHS Change Model Team and NHS Improving Quality

Ashley Brooks - Patient Champion

Nicola Mann & Team - Straker Films

James Haddow - Surgeon

Miles Ayling – Director of Innovation and Service Improvement – NHS England

the people from the NHS and from around the world who made comments about our entry on the MIX website and enabled us to improve the way we have told our story

We have really appreciated being a finalist in the "Leaders Everywhere Challenge". It has made us reflect deeply as a team and seek counsel from others. As a result, NHS Change Day 2014 will be much improved.

Thought leaders who have inspired us:

Saul Alinsky whose “Rules for Radicals” is a powerful manual of leadership tactics that can be contextualised to organisational settings

Paul Bate and Glenn Robert for helping to translate social movement theory into approaches to large scale change in the English National Health Service

Peter Fuda for helping us understand the difference between fear based urgency (burning platform) and burning ambition

Marshall Ganz who made social movement principles really practical for us and taught us skills for large scale change

Gary Hamel because so many soundbites in “What Matters Now” are profound words of wisdom for NHS Change Day. We think you wrote it for us.

Lois Kelly who helped us understand that that being a rebel is a good thing and quite different to being a troublemaker

Nilofer Merchant for teaching us about the social era, community, collaboration and onlyness and for being an inspiring role model

Deborah Meyerson who showed us how to walk the thin line between conformity and rebellion, inside and outside, difference and fit; how to rock the boat AND stay in it

We plan to celebrate in July to share the stories and difference made to patients and to challenge the status quo.

The key lesson for me this year the way we go about change needs to change. We need to think about engaging people in change in a completely different way, through building relationships and a theory of change that ignites individual motivation that can inspire collective action.

This year the majority of people heard about change day and got involved through word of mouth and within their own organisation.

We thought we should update you about what has happened since NHS Change Day 2013.

NHS Change Day 2014 took place on 3rd March 2014. The number of pledges this year has hit and exceeded the 500,000 mark. The day was truly amazing. Just look at the hashtag #NHSChangeDay to get a sense of it. NHS Change Day is a genuine grassroots social movement, involving leaders everywhere, seeking to make a difference for people who use our healthcare system.

We also ran a virtual school as part of NHS Change Day 2014 called “The School for Health and Care Radicals” www.changeday.nhs.uk/healthcareradicals . The aim was to equip frontline staff and patient leaders with the skills and self-efficacy to make changes in their own services. 1,300 people signed up for the school, along with 90 volunteer mentors. We are currently awarding “virtual badges” to those demonstrating they have applied the learning to make a difference to patients, through their pledges for NHS Change Day. We have started evaluating the outcomes and it all looks good.

Of course, pledges for Change Day mean nothing if they don’t result in action that makes a difference. Now we are following up, organising, learning and capturing. It’s very, very important to us to be able to show the impact and outcomes of Change Day 2014.

Colleagues from Scotland, Wales, Northern Ireland and the Republic of Ireland joined in with Change Day. In 2014, Change Days are also taking place in Australia, Sweden, Denmark and the Netherlands.

We estimate that 99% of the action came through volunteerism; people did this because "they wanted to" not because "they had to". This just shows what happens when we are able to ignite the passion, commitment and activism of tens of thousands of grassroots healthcare leaders and patient leaders.

On behalf Connecting with People, the Royal College of Psychiatrists and all the pledge supporters we would like to congratulate Helen Bevan and the NHS Changeday team for leading an extraordinary event. It was an honour to be a part of such a special event and to be able to promote hope and help to people in distress. Tragically suicide rates are increasing globally and stigma and lack of awareness are barriers to people accessing the support they need – which ultimately might prove life saving. The International Association for Suicide Prevention in collaboration with the WHO urge that ‘new, innovative methods that creatively use the emerging social media need to be developed and tested’. Suicidal thoughts usually start because people feel overwhelmed by their problems or their situation. People find it hard to ‘see a way out’ and even though they may not necessarily want their life to end - they cannot cope with their emotional or physical pain any more. Many people do not know how to approach someone who they think might be suicidal. NHS Changeday provided an excellent platform, underpinned by mass action and grassroots innovation to share a powerful and positive suicide prevention message of hope and where to access support. This is particularly relevant given new research showing suggesting that hope and optimism can be potential protective factors against suicide.

The way that Connecting with People and the Royal College of Psychiatrists mobilised a social movement-worth of people around a compelling pledge, epitomised the spirit of NHS Change Day.

We hope other people will click onto your website http://www.connectingwithpeople.org/ucancope and engage with your important work. We look forward so much to our on-going collaboration in NHS Change Day 2014 and beyond.
Helen Bevan

Today is the 6 months anniversary of change day. I am even more inspired when I hear very single story and feedback about the fantastic follow through on pledges that people have made, holding themselves to account and inspiring leaders everywhere. It's a tribute to everyone who continues to keep the flames going and champion being change makers to improve the care of patient who we serve everyday. I had a case study sent to me from a community nurse who I had never met sharing their pledge to be more efficient as a team, some might think that was nebulous and not specific enough. Well this team took TOFU (Take Ownership and Follow Through) seriously. They organised themselves to rework a workforce tool and implenented it as a team and as a result have saved thousands of pounds for their Trust but more importantly they say is they have saved time for more patient care. The Trust are now going to roll it out and the team have been nominated for 2 awards. It cost them nothing but the determination to improve, and the energy to want to make a difference. When you inspire be prepare for amazingly things to happen. And it certainly makes getting out of bed everyday easier. It doesn't matter where you are in the system to be a leader is just to make a difference.

Today, 13th September 2013, is the 'six month' anniversary of NHS Change Day. Its legacy is lasting, momentum is building and social media is buzzing today with people recounting their experiences post-pledge and sharing their ideas for Change Day 2014.

The authors of this entry have posted a new film today on YouTube, showing the results of the survey we ran after Change Day 2013 so that we could understand its impact: http://youtu.be/of8ILIMHMe8

A series of key opinion leaders of the English National Health Service (who are not necessarily those with positional authority) have shown their support today. This is today's blog from Roy Lilley, number one social media influencer in the NHS context: http://t.co/fjCv2StPkK

NHS Change Day ignited a fire which continues to burn brightly. There is such a sense of hope and possibility. It doesn't cost a fortune to create a "game changer" for better patient care. It just needs us to liberate and mobilise our "leaders everywhere"; the people who really want to make a difference. The resources for healthcare transformation are right under our noses. We just need to see them, believe in them and activate them.

There are many lessons in this NHS Change Day story especially valuable for people in large organizations, particularly:
1. People engage around what they value, in this case providing excellent care in a caring environment.
2. People need a call to action, as in the Change Day pledges.
3. People are more likely to commit to small changes within their control than being on endless task forces around complex, giant issues.
4. People inside organizations have extraordinary and plentiful ideas for how to evolve their organization from where it is today to a much better place. The volume and diversity of pledge ideas from NHS Change Day demonstrates this.
5. Everyone benefits from a deadline. In this case, one day where everyone would be all in.
6. Social sharing helps everyone in an organization learn from one another, and find new ideas that they could adopt in their workplace. It also helps people learn about their colleagues, building professional connections in an authentic way. Far better than so many top-down forced "employee engagement" initiatives.
6. Empowering, relatively easy "asks", e.g., making a pledge for one day, can contagious -- something to talk about, a welcome diversion from business as usual, and, well, fun. And the best change -- even in the most serious organizations like health care -- comes when we are fully alive and enjoying our work.

Hi Lois
We really appreciate your reflections on NHS Change Day. You have been a great source of inspiration to us as a team, particularly in our "moonshot" goals about engaging the dissenters. If we are going to be effective change agents in healthcare, we have to challenge the status quo so that makes us all dissenters. Your framework on the difference between "good rebels" and "bad rebels" (or "rebels" and "troublemakers") is at the heart of our thinking. In our context, there is all the difference in the world between a "rebel" (who is focused on the mission of the NHS; who is optimistic, passionate and able to take collective action with others) and a "troublemaker"(who is angry, pessimistic and alienates others). The problem is that sometimes leaders with positional authority regard rebels as troublemakers and are unable to harness the incredible energy for change that these rebels represent. As a result, lots of people who start off as rebels get so frustrated they end up as troublemakers. Through NHS Change Day going forward, we want to engage half a million dissenters in healthcare and build a movement of rebels to help secure the future of the NHS. Every new truth starts as a heresy; big changes only happen in organisations because of the heretics, dissenters and radicals. As you say in your comment, we need mechanisms like Change Day to create focus on what really matters.
Thank you!

As a team of authors, Pollyanna, Jackie, Joe, Damian and I have rewritten and resubmitted the story of NHS Change Day. We wanted to say a big thank you to everyone who took the time to put a comment about our submission on this website.

For the commentators who are "NHS Change Day veterans": you got the spirit of Change Day across so beautifully in your comments. It inspired us as we rewrote our narrative and helped to shape our revised conclusions. We hope that what we have written has been able to capture that same spirit

For the commentators from other health systems globally: we so appreciate your endorsement and support and look forward to collaborating to build a worldwide movement of "leaders everywhere" in healthcare, making a difference for millions of people who use our services

For commentators from other industries: thank you for your helpful reflective comments. We are all users of healthcare services and we have a collective vested interest in helping to make the healthcare system as good as it can be.

Change Day fundamentally changed the way I thought about engagement and connection. It was phenomenal to be a part of it and the power that was created by commitment rather than compliance. The even more inspiring element of this was that it was undertaken in the most hierarchal organisations in the world. The breaking down of barriers and liberating staff to make a difference was brilliant - and I know it made a difference to people's lives (both staff & patients) .

Change Day fundamentally changed the way I thought about engagement and connection. It was phenomenal to be a part of it and the power that was created by commitment rather than compliance. The even more inspiring element of this was that it was undertaken in the most hierarchal organisations in the world. The breaking down of barriers and liberating staff to make a difference was brilliant - and I know it made a difference to people's lives (both staff & patients) .

I find the rapid development of this movement very impressive, from a twitter correspondence to more than 189,000 pledges in just a few months. Gaining such support from so many employees across different professions, specialties and levels of seniority is truly inspiring. I look forward to NHS Change Day 2014!

Movements like this can and will start to break down hierarchy getting the front line back to make changes improving patient care. Congratulations an amazing achievement which has created an appetite to make those small changes be something bigger and better next time.

This is a wonderful example of grass roots social action. From little things big things grow. I am inspired that Australia might be able to follow the lead and join with NHS in 2014 to make this an even bigger movement. Congratulations in making it to the finals but even bigger congratulations for making it to 189,000 pledges !

This has to be the greatest leadership success story of all time! It proves that the NHS is packed to the brim with leaders at all levels - all 189,000! We often talk about leadership and what a differnce it makes in the NHS, times it by 189,000 and that is an achievement and commitment from dedicated staff that words cannot express.
When I think back to March it was such an exciting time, it felt amazing to be part of something so huge - it was like 189,00 people standing in unity holding hands and saying 'we care' and 'we will not be defeated'. We pledge to make a difference to patient care. I chalenge any other healthcare system to be as brilliant as the NHS!

Kirsty I am so inspired by your comments, I'm extremely proud to be part of the nhs and part of NHSCD! The energy that has been released is phenomenal! Just imagine what we could do 189,000 times over! Leading in the new world of connections and networks need a different mindset and making an emotional connection is not only required but expected. Every pledger everywhere should be proud of their collective effort.

An outstanding story. At their core, people in healthcare share a common set of goals: they are passionate about patients and helping people get well. They want to avoid harming patients, and like all people, they don't want to be miserable at work. People want a voice, and those who spend the bulk of their time at the front lines also see the best and the worst of a system. Finding a way to unleash that passion and shared vision, to engage people to make their patients lives better while making their own lives better is a brilliant way to drive change. Amazing story and we are going to open a similar discussion. This is entirely replicable.

Rahul I agree and we plan to replicate it in 2014! Watch this space and we want to make it bigger and more impactful. More patients benefitting and more grassroots staff pledging to make the NHS a better place, there is loads of great practice but lots we need to improve so let's build on what's good and replicate it everywhere.

NHS Change Day was a bit of a turning point for am and came just at the right time for many . Seeing in action the powerful effects of creating the right conditions for people to unleash and act on their ideas and turning these into commitments was truly inspiring.Being part of this was amazing too - we ran 3 workshops on the day as NHS England Nursing directorate .We worked with 50 practice nurses, 100 caremakers ( student nurses and newly qualified nurses) and 50 new nurse commissioning leaders . The turning point for me is really appreciating the power of letting people discover their shared purpose - value driven intent ,and allowing the space for them to develop the trust and confidence to then create and act . This is what we try to do now with the continued work we do with these three talented groups and others . Helen has helped us along this journey and as we begin to tackle some wicked issues ,the focus on creating the right conditions for unleashing talent at all levels is crucial . NHS Change day was a great idea ,perfectly executed and unleashed talent and energy in so many people ,teams and organisations .The event was not a one off for me and the team I work with ,it has been a continued process for us to manage our objectives and achieve the quality improvements we can truly connect to personally and professionally . Thanks to all the NHS change day leadership team :)

I spend my days working with talented, passionate healthcare professionals who are often caught between the enormous desire to create change to improve patient care and the bewildering frustration that comes with dealing with endless politically motivated 'top down' change initiatives that resturcture organisations and disrupt relationships. It's no wonder they're often exhausted. Change day was different. It started from genuine passion to do something, anything that can make a difference. It didn't rely on enormous political backing, infrastructure and committees. Rather, Change Day enabled hundreds of thousands of sparks of good ideas to come together in one roraring fire. I have seen people grown in confidence from seeing their difference make a difference. It gave confidence to those who thought 'me? surely I can't do anything' to step out and give it a go. It is a tremendous testimony to the spirit and energy of the NHS and to the small group of passionate professionals behind it.

Liz as one of thousands of people who feel passionate about the NHS the burden of bureaucracy has never more been felt, I think when you ignite people passions and energy the possibilities are powerful. I have seen junior staff and senior leaders respond to this in a way that has given me great hope personally at a time when I thought I had not much more to give myself. So it has reawaken my own passion. As you say the confidence that it has given to everyone who pledged is testimony to growing leaders everywhere who feel they can take action and make a difference wherever they are in one of the biggest systems in the world.

This is a terrific example of how to drive change by creating the right conditions for emergence. The NHS Change Day shows the impact that can be achieved when you combine clarity of intent (a shared purpose to improve the system) with the collective talents and passions of a hugely diverse range of individuals. Although there were clear design 'rules', it wasn't prescriptive, and the results speak for themselves. When you create an environment of trust, the depth of people's creativity, productivity and enthusiasm is staggering.

Josie I couldn't agree with you more one of the outcomes from change day has been this real identification with giving people permission or allowing ourselves to take permission and I feel those whose took action on change day just represent the thousands of people who want to do that everyday but don't feel the permission to do so or are not in the right environment, but if they were imagine what would happen!

Big questions get asked like, “how do we create a workforce of healthcare professionals with the philosophy and skills of healthcare improvement in their DNA?”, get asked all the time. NHS Change Day 2013 has those answers and is a blueprint for inspiration, social organising and leadership.

The NHS Change Day 2013 leaders have shown us that it is possible to mobilise thousands around a shared common goal, bring boundless joy to those participating, and show millions of patients and their families that their healthcare providers really care about the quality and safety of the healthcare they receive. The world is a better place for NHS Change Day 2013 and its sequel is eagerly awaited…

Andy the challenge this year is even more exciting than last, (but scary too!) I can't tell you how many people have contacted us who want to support us this year, it has been overwhelming. It tells me the spirit of voluntary action is alive an kicking and people just want to opportunity. We have created the environment for change and that is the role of NHS change day and then the rest is available to everyone to take the plunge, thank you for participating...

NHS Change Day 2013 was a first. It was new, and it was innovative. When the same old ways of the past were seen to be struggling we had the courage to look elsewhere at success, to adapt, and to try something different. NHS Change Day distributed leadership throughout the system and gave anyone, from within or outside the service, the opportunity, permission and support to lead a change about which they felt passionate. This was clearly demonstrated in the smashing of its original ambition of 65,000 pledges. Indeed, NHS Change Day reminded us, perhaps taught us, that the power to change - to improve services for patients and their loved ones - exists in all of us and it is with the right approach, a shared purpose, and an asset-based model of improvement that we can all fulfil our potential as leaders of change and grow the stock of leadership capital. The bar has been well and truly set for NHS Change Day 2013's successor. With the learning to date, palpable momentum and energy created, and new leaders in the making and emerging, the next NHS Change Day can only be eagerly awaited.

What a success story. Not just about creating change but one of passion, commitment, shared purpose in making the NHS 'better' - a story of love. Love for the service , the people who work in it and for those it serves.
Proud to have been a part if this and see the passion and actions of other like minded people dispel the myths of what was 'possible'! A reminder that together we can change the world.

Being part of NHS Change Day was inspiring and rewarding. It was like everyone participating was connected through a common desire and that the result was something bigger than the sum of all the pledges. The closest thing I have to compare is when I ran the Royal Parks half marathon for charity. Although I didn't know the other runners and I was raising money for my own chosen charity, it felt great to be part of the whole event and to give some of my time and effort away for the good of others.

That's a great observation James. There was certainly a sense of togetherness, especially on the day, which went beyond just the context of Change day itself. I think one of the things we were able to mobilise was peoples' passion about the organisation they work for. Yes, there are many frustrations, controversies and sadness but overall Change Day reminded people of the great things that could, and do, happen. I am sure the runners and yourself felt proud to part of the charity in the same way many of those on change day felt proud of the NHS.

As is clear from this article the impact of NHS Change Day is still being felt - which is one of its great strengths. Personally I am still working on one of my pledges (it's not a short term thing) and as I do so more pleades come to mind - things I can do myself to improve our NHS. To me this is one of the key strengths of the NHS Change Day approach. It mobilised all of us! And there is so much more still to do but we do have the will and the power to make change happen, each of us playing our part. It is a privilege to be involved in improving the NHS for patients and to work with so many inspiring people who hold true to themselves and thier values in often difficult circumstances.

It is right - the results for change day are still being felt! It is great to see your enthuaism for the day and it was a priviledge to have you involved in the process. Change day allowed everyone in the NHS to work on an even platform to make a difference, not being constrained by the traditional boundaries. Looking forward to change day 2014.

The Vision of Helen, Jackie, and everyone else leading this event should not be underestimated. Many great ideas fail to come to fruition due to a "it will never work attitude" The team involved in Change Day have shown that with enthusiasm, organisation, thought, and a the right attitude, so much can be acheived. Although 189 000 pledges was an amazing outcome, I feel that there is more to come. The NHS is at a time where it needs to mobilise around a good news story. This could be it. The themes established in the initial NHS Change Day are internationally relevant. With thought and willing Change Day could become the biggest quality improvement healthcare event in the world. Now that is something to get really excited about. There are lives to be saved, healthcare to be improved... patients and staff need to be given back power to change.

Russell we had many people who said it wouldn't work, but for everyone there were hundreds that believed it could. I learned however that the energy of each nay sayer was really consuming and image staff who feel that everyday on the frontline! It makes me more inspired to support our fantastic staff who give their best everyday. The poor practice we experience in the NHS is totally unacceptable and we want leaders everywhere that feel they can stand out, be bold and create the change we want to see in the NHS.

It was great to spend NHS Change Day with the Care Makers - emerging clinical leaders made up of student & newly qualified nurses & midwives. They embodied the spirit of this approach & I'm looking forward to carrying this forward as we engage more Care Makers and use this model in practice. Thank you to Helen for sharing the day with us and providing an inspirational force.

Thanks Michelle - an energising drive for Change Day was the enthusiasm of so-called "emerging leaders". This term may do the students and newly qualified's an injustice though as it implies a few whereas an entire generation have a part to play in re-affirming and re-invigorating values in the NHS. Care makers have an instrumental part to play in this and it was great to to see yourself, Jane Cummings and others embracing Change Day as a means to spread the word.

It was great reading this story as I've seen people really engaged with this. It's a bold approach , that has led to amazing results. What is more gratifying is that great financial results will be achieved, through collective efforts of happy employees. Really mind boggling.

Thanks Ade - love the use of the word 'Bold". I don't think we considered it in that way at the outset but it was a term used by many, especially senior leaders of organisations, to describe what we had done. As Voltaire said "Be bold, proclaim it everywhere: They only live who dare". We dared to challenge people they they could deliver improvements in a variety of places and ways and the people certainly delivered!

NHS Change Day had that buzz about it right from the very start, from the very first time I heard about it and retold the story over and over again - that feeling never subsided. Given what was happening in the NHS at the same time as Change Day, it was an amazing day.... a day when we focused on what we could do - not what we couldn't do. It felt right and it felt personal to each and everyone of us. That feeling and commitment is what the NHS is built upon and is what makes it great and progressive. It's not politics or organisational reform, it's about people wanting to do things better and do better things. The knowledge that so many other fellow NHS people - staff, patients and supporters were doing something on the same day was inspirational and we can see it has made a real difference to the people we serve, and this is just the beginning....

Thanks for the endorsement, Elaine. You are right that this is just the beginning.....Healthcare leaders from many different countries picked up on the excitement around NHS Change Day and have been in touch with us to say that they would also like to have a "Change Day" for their health system in 2014. So we are currently engaged in some global conversations to see if we can collectively make this happen on the same day and to see if we can identify a specific action that will unite clinicians, patients and healthcare managers across the world. If everyone takes a little bit of responsibility for change, we can make so much positive improvement happen.

This initiative shows that the rules of engagement have changed. Anyone wanting to see and influence the positive transformation of the NHS will need to understand them. We live in exciting times and I hope NHS Change Day goes down in history as the beginning of something very special.

The staff of the NHS have so much enthusiasm for the work that they do, but we should never underestimate the physical and emotional cost of caring. The challenges of ensuring patients are well cared for whilst having beds available for those requiring care, delivering complex treatment regimes, ensuring people and their families are effectively communicated with, whilst addressing gaps in staffing rotas, administrative challenges such as lost notes etc mean that we focus on the here and now rather than ‘what could be’. NHS Change day provided that window of opportunity to think differently, sparking thoughts of, ‘Shall we’ which soon became ‘lets do’ it was empowering. I do not think we’ll fully appreciate the impact of NHS change day, there were superb pledges and clear outcomes, but it also created sparks in staff who were given ‘permission’ to make change happen that will flicker and with a little bit of encouragement will grow into a fire. We need all staff in the NHS to believe that they can and have’ permission’ to make change happen, NHS Change day started that belief and it’s a powerful legacy.

Thank you for your comments Kath. You are right the NHS staff do have a lot of enthuasiam for what they do, despite challenging circumstances. We did work had to ensure that NHS staff could feelk empowered to make a difference and in turn improve patient care. It has left a powerful legacy, which is making a difference even now for both staff and patients. I hope you will help us continue the journey into 2014.

It was an honour to see firsthand the work and energy of the leading figures behind this initiative. The palpable sense of momentum and ambition was infectious. That spirit quickly spread and, as the story testifies, expectations were wildly exceeded. The staff who work in the NHS, even more so than the public who treasure the service, have a stake and commitment in this most British of institutions. The reality is the service is made up of staff, teams, organisations and systems and isn't a single national organisation. This initiative enhanced our sense of belonging and ability to influence the branch of the service we work in daily. The often felt remoteness of efforts on increasing productivity or influencing improvement was overcome by grass-root 'pledgemakers' with their sense of personal responsibility and inspiration. NHS Change Day broke the mould and changed thinking; it genuinely was a game-changer as the article describes. Reading the excellent article refreshes the sense of what happened and the scale of what's possible.

Thank you for the positive comments Charlie. I thought you might be interested to hear about feedback so far from NHS Change Day 2013 which is helping us to plan NHS Change Day 2014. Respondents tell us that "learning from others" and "supporting colleagues" is as important as "improving patient care" in motivating people to be involved. It just goes to show how looking after staff and colleagues leads to better patient care. Also 80 per cent of respondents said they had shared what they were doing for Change Day with others, the majority of people said it caused a change in their personal behaviour and the majority of pledges has led to a long term impact in their organisation. We want to turn NHS Change Day into an on-going transformation process, not just an annual event. We have a fantastic platform for doing this.

I used to teach people , organisations and sales forces how to sell, NHS Change Day is the biggest sales training event I have ever known, it was HUGE, I loved it.

The most important word any sales person could ever posses is NETWORK. Simply build your net, carefully sewing it with quality and size in mind and then put your net to work for you – network. NHS Change Day provided both the net and how you could put your idea or pledge to work.

NHS Change Day gave us all permission to do something small or big personally, locally or on a national scale, with no order, no score, no condemnation but one of togetherness and solidarity, solidarity for the goodness and protection of our beloved NHS.

In simple terms it showed how much people care for the NHS in complex terms it showed how much people cared for the NHS.

This is an amazing initiative and perhaps shows how you can unleash the frustrations into really positive action. The only thing for leadership to fail is for good followers to do nothing. This is a great example of followers picking up the baton and running with it. True leadership is about the relationship to the followers and how you can empower them to act. Sometimes there is a fear of freedom and it is safer not to be responsible however this approach can provide the courage for others to act. Great stuff!

Thanks Julia. What shocked me was how many frontline staff in the NHS felt they needed to "ask permission" from their leaders to take an action for NHS Change Day. Just because we are in a hierarchy, it doesn't mean that the only time action happens is when leaders decree it will happen. When we set up Change Day itself, we didn't ask anyone in the NHS leadership hierarchy for permission, we just decided to do it, made it happen and got local and national leaders on board. We hope that Change Day has shown many NHS frontline staff that they don't need to ask permission to make positive changes for patients. We also hope it has shown NHS leaders how to unleash the creativity and energy of their teams. Like John Kotter suggests in "Accelerate!", we have a hierarchy and a network operating simultaneously to deliver change at scale.

NHS Change Day is a simply extraordinary initiative to have been involved in. The levels of imagination, energy and commitment that it unleashed was unprecedented. And its momentum and reputation hasn't ebbed away after the first official 'Day' - if anything it is continuing to build across the NHS.

We are now increasingly being seen as a powerful force for grassroots change and improvement not simply as an end or project in itself, but in relation to the core challenges facing the NHS. For example, we have recently been invited to support a series of regional events organised by the Department of Health team constructing the Government's response to the Francis Report.

The first of these took place last week and the audience contained a number of people who had made pledges for NHS Change Day. All of them told us that, far from making a pledge on a single day and leaving it there, they took their pledge as a spur for permanent and on-going changes and improvements in personal and organisational behaviour.

I believe this shows that the energy unleashed by Change Day - coupled with its unique approach to mobilising the grassroots according to social movement principles - could prove to be a significant moment in NHS history.

"Energy Unleashed" - not just a strap line for a movie but also the end result of Change Day! Thanks Joe, and also for the observation around permanency of change. Some were challenged by the fact Change Day was just "one day" but the response from the participants has been to drive on with a number of pledges. This instinctive initiative was more than we could have hoped for and shows what can happen if the power, and responsibility, comes bottom up rather than top down!